BMJ  2005;331 (17 December), doi:10.1136/bmj.331.7530.0-f

Editor's choice

Bentham's head

Not far from the BMJ, near the entrance hall of University College London, sits Jeremy Bentham, the great 18th century educator and benefactor—and the father of utilitarianism. His body was preserved on his own instruction as an "auto-icon" but his head, damaged in the preservation process and for a long time stored under his chair, is now locked away safe from student pranks. The head on his body is made of wax. Why do I mention all this? Because this week's journal echoes Bentham's philosophy—that our aim should be to acheive the greatest good for the greatest number of people. It's a philosophy that seems hard to argue against. But as articles in this week's journal show, the devil is in the detail.

This week we publish the final two articles in the series on cost effective strategies for achieving the millennium development goals (p 1431, p 1457). As a means of deciding how to achieve the greatest good for the greatest number, you won't get much better than this—cost effectiveness analyses based on systematic reviews of randomised trials, in which the authors uniquely take into account the fact that interventions don't act in isolation. The good news is that there is no shortage of highly cost effective strategies for developing countries. The bad news is that there is a dire shortage of funds: $18.5bn, to be precise. Given this funding crisis, the authors have done the world an important service in identifying what to prioritise when resources are tight. As they say, governments and others will be more willing to give money if they think it will be used effectively.

As a strategy for acheiving rational use of limited resources, it's hard to beat well trained and motivated generalists (p 1462). Broadly based diagnostic skills are, say Iona Heath and Kieran Sweeney, "a uniquely valuable healthcare commodity." The subtext of their article is that we undervalue these skills at our peril. And indeed, the United Kingdom's primary care led healthcare system is the envy of much of the world, as was confirmed to me at a meeting of our US advisers in Phoenix, Arizona, last week. Sadly though, the inverse care law is still with us (p 1449)—those in need are least likely to receive the best care—which means that interventions aimed at improving health for the poor tend to help the better off more. One solution for UK primary care, say Mackay and colleagues (p 1449), is to create the most attractive career opportunities where the need is greatest. For the wider world, there is no magic bullet for tackling inequity (the unrestrained market is certainly not one, p 1464, p 1483), but a new report from the World Bank provides many examples of how to reach the poor in different settings (p 1417).

I started out on this column feeling rather gloomy, but summarising all this encouraging stuff has left me more optimistic. With all these good people arguing on the side of right, sense will surely prevail. Which means I can, with some relief, put aside the rather complicated picture I had in mind when I started—of Jeremy Bentham with his head in his hands.

(fgodlee{at}bmj.com)

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Relevant Articles

Reaching the poor

Tessa Richards
BMJ 2005 331: 1417. [Extract] [Full Text] [PDF]

Deprivation and volunteering by general practices: cross sectional analysis of a national primary care system

Daniel Mackay, Matt Sutton, and Graham Watt
BMJ 2005 331: 1449-1451. [Full Text] [PDF]

Medical generalists: connecting the map and the territory

Iona Heath and Kieran Sweeney
BMJ 2005 331: 1462-1464. [Extract] [Full Text] [PDF]

Using markets to reform health care

Nigel Edwards
BMJ 2005 331: 1464-1466. [Extract] [Full Text] [PDF]

Comprehensive ophthalmology at the Last Chance Saloon

Michael Clarke
BMJ 2005 331: 1483. [Extract] [Full Text]

Cost effectiveness analysis of strategies to combat HIV/AIDS in developing countries

Daniel R Hogan, Rob Baltussen, Chika Hayashi, Jeremy A Lauer, and Joshua A Salomon
BMJ 2005 331: 1431-1437. [Abstract] [Full Text] [PDF]

Evaluation of current strategies and future priorities for improving health in developing countries

David B Evans, Stephen S Lim, Taghreed Adam, Tessa Tan-Torres Edejer WHO Choosing Interventions that are Cost Effective (CHOICE) Millennium Development Goals Team
BMJ 2005 331: 1457-1461. [Extract] [Full Text] [PDF]

Rapid Responses:

Read all Rapid Responses

Bentham must still be grieving, indeed!

BM Hegde
bmj.com, 16 Dec 2005 [Full text]

spelling of trialling

anne p collins
bmj.com, 19 Dec 2005 [Full text]